Healthcare Provider Details

I. General information

NPI: 1700278850
Provider Name (Legal Business Name): LIFEBRIDGE INTERGRATED CARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1293 PROFESSIONAL DR SUITE D
MYRTLE BEACH SC
29577-5754
US

IV. Provider business mailing address

2443 NC HIGHWAY 20
SAINT PAULS NC
28384-8652
US

V. Phone/Fax

Practice location:
  • Phone: 312-730-0662
  • Fax:
Mailing address:
  • Phone: 312-730-0662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. SHEILA MURPHY
Title or Position: CEO
Credential:
Phone: 312-730-0662